Lymphoproliferative Disorders - PowerPoint Presentation

1. Lymphoproliferative Disorders

2. Definition Lymphoproliferative disorders are a heterogeneous group of malignant clonal proliferations of lymphocytesClassified as sub-types of non-Hodgkin’s lymphomaB-, T- and NK-cell lineages

3. CD (claster differentiation) antigenes of B-cellsPluripotent stem cell – only CD-34, is absent on pre-B-lymph-sCD-10 – the earliest В-cell AG. Is present on blastsCD-11a – hairy В-cellsCD-19 CD-20 CD-22 – precursors of В-cellsCD-38 CD-85 – plasma cells antigenes

4. CD (claster differentiation) antigenes of T-cellsCD-7 – the earliestCD-3 CD-5 CD-2 – mature cells (thymus)CD-4 → T-helperCD-8 → T-supressorCD-57 CD-16 → NK

5. B-cells maturing stagesAG-non-dependedAG-dependentIn bone marrowUnder influence of interleukinsIn lymphatic organs (spleen, lymph. nodes, tonsils)Under AG-stimulation, with T-cells

6. 1– lymph. node3 – herminative center– dark zone: centrocytes– AG selection4A – herminative center– light zone: centroblasts – reproduction of selected B-cells4Б– mantle zone: immunoblasts – processing of memory cells and plasma cells5 – marginal zone: mature В-cells

7. Classifications1832 - Thomas Hodgkin: first description of lymphoma 1966 – Rappaport 1973 – BNLI 1974 – Like/Lennert 1974 – Lukes/Collins 1976 – WHO 1982 – Working Formulation 1994 – REAL 2001 – WHO, updated 2008

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9. Etiology Requires a number of distinct transforming events to occur within the affected cellsRisk factors areAltered immunityInherited syndromesataxia telangiectasiaWiskott - Aldrich syndrome common variable immunodeficiencyImmunodeficiency due to past medical historylong-term immunosuppressive drug therapy, transplant recipients patients with autoimmune diseases Infections (HIV, HTLV-1, HHV8, EBV, H. pylori)Occupational links: herbicides, pesticides, Petrochemical industry, asbestos exposed workers, nickel refinery workers Lifestyles and other exposures: Ionizing radiation, Little conclusive evidence as regards dietary factors and electromagnetic fields

10. Clinical FeaturesAnnual incidence is approximately 10/100,000Elderly (median 65 year) M:F ratio 2:1Chronic B-cell lymphoproliferative disorders account for more than 90% of lymphoid malignancies T-cell and NK-cell neoplasm being relatively uncommon

11. Clinical presentations and natural histories of chronic lymphoproliferative disorders are extremely heterogeneousMany patients are asymptomatic at the time of first presentation, with the diagnosis being made as an incidental finding after a routine medical examination or blood test, for example, CBC

12. Patients may present with lymphadenopathy, systemic symptoms such as weight loss, night sweats and fever or the symptoms of anemia and thrombocytopeniaEnlargement of the spleen and, less frequently, the liver Hyper viscosity symptomsDefinitive diagnosis is made on the characteristic lymphocyte morphology and immunophenotype usually from samples of peripheral blood or lymph nodes

13. LymphocytosisLymphocytosis is defined as an absolute lymphocyte count exceeding 4 x 109/liter (4000/ul)Monoclonal lymphocytosis lymphoproliferative disease (because of an intrinsic defect in the expanded lymphocyte population)Polyclonal lymphocytosis ( secondary to stimulation or reaction to factors extrinsic to lymphocytes, generally infections and/or inflammation)

14. Characterization of cell surface markers is valuable in distinguishing primary lymphocytosis (leukemic) from secondary lymphocytosis Analysis for immunoglobulin or T cell receptor gene rearrangement also may provide evidence for monoclonal B cell or T cell proliferation, respectively

15. The blood film of patients with lymphocytosis

16. Peripheral smearSmall lymphocytes with clump chromatin scant cytoplasm + smudge cells =CLL

17. Atypical CLL-less condensed chromatin and irregular nuclei

18. Medium size cells, round nucleus, moderately condensed chromatin, prominent central nucleoli, scant basophilic cytoplasm – prolymphocytic leukemia

19. Small to medium size cell, oval to indented nuclei, slightly less clumped chromatin, abundant cytoplasm, circumferential hairy projectionsHairy cell leukemia

20. Mature B lymphocytes with pale cytoplasm, irregular cytoplasmic borders, and polar villous projections-SMZL

21. Scant cytoplasm some cell shows clefting – follicular lymphoma

22. Small to medium size cells slightly irregular nuclear contour - like mantle cell lymphoma

23. Large granulocyte - T cell large granular leukemia/lymphoma

24. Large lymphoid cells irregular nuclei, basophilic cytoplasm (flower cells)-adult T cell leukemia/lymphoma

25.  Large lymphocytes with ceribriform nuclei and scant cytoplasm-sezary syndrome

26. Ancillary diagnostic studiesUse of immunologic/molecular techniquesMalignant lymphomas reproduce the immunobiology of their benign counterpartsThis reproduction may be aberrant, and hence distinguishable from normalExpression, normal and aberrant can be used to:Determine lineage, B versus T versus NKDetect clonalitySuspect malignancy- loss or aberrant expression of expected antigensRecognize characteristic patterns of antigenic expression associated with certain subtypes of lymphoma

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28. Normal lymphoid maturationRequires two major activitiesThe production of a unique antigenic receptor on it's surfaceThe expression of several surface proteins necessary for antigen recognition, cell activation, cell-cell communication. Antigen receptors are generated through the process of "genetic rearrangement"- the random selection and then juxtaposition of discontinuous genetic segments encoding the antigen receptor genesB cells Immunoglobulin receptor composed of two heavy chains and two light chainsSelect specific heavy chain gene sequences Select only one of two light chains, kappa or lambdaT cellsSelect one of two heterodimeric receptorsAlpha/Beta heterodimer T cell receptorGamma/Delta heterodimer T cell receptor

29. Surface antigen productionImmune cells require numerous surface molecules for effective immune response, cell-cell communication and regulationClassified into B cell associated, T cell associated, activation associated, cytokine receptorsExpression occurs in an orderly sequence in lymphoid maturation Antibodies to these molecules cataloged through the CD - clusters of differentiation - numerical system.

30. Lymphomas frozen at various stages of antigen dependent B cell maturation and differentiation

31. T cell antigen expression

32. Immunologic TechniquesFlow cytometryImmunohistochemistryBoth utilize monoclonal antibodies to detect clonality and unique antigenic patterns

33. B cell lymphoma

34. DefinitionMature B cell neoplasms are clonal tumors of mature B cells at various stages of maturationThey recapitulate normal stages of maturation.

35. B cell Development

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37. Indolent versus aggressiveIndolentSmall lymphocytic lymphoma/CLLFollicular lymphoma, Grades 1/2Extranodal Marginal zone lymphoma of MALT typeNodal marginal zone lymphomaSplenic marginal zone lymphomaHairy cell leukemiaLymphoplasmacytic lymphomaPlasma cell myelomaPlasmacytomaCutaneous T cell lymphomaCutaneous CD30+ anaplastic large cell lymphomaAggressiveProlymphocytic leukemiaLarge B cell lymphomaBurkitt lymphomaMantle cell lymphomaAnaplastic large cell lymphomaAll peripheral T cell lymphomas

38. Clinical Characteristics of PatientsDiseaseMedian Age, yearsFrequency in Children% MaleStage I/II vs III/IV, %B Symptoms, %Bone Marrow Involvement, %% Surviving 5 yearsCLL/SLL65Rare539 vs 91337251Mantle cell lymphoma63Rare7420 vs 80286427Splenic marginal zone B cell lymphoma60Rare4867 vs 33191474Follicular lymphoma59Rare4233 vs 67284272Hairy cell leukemia50Rare8021vs 792510090

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41. 41SLL/CLL Clinical featuresoften asymptomatic Non specific : Easy fatigability, Weight loss, anorexia Generalized lymphadenopathy and hepatosplenomegaly in 50- 60%Hypogammaglobulinomia (>50%)Presented in old ages (>50 years)

42. 42SLL/CLLMost patients are leukemic at diagnosis

43. 43SLL/CLL MorphologyEffacement of normal architecture by Sheets of small round lymphocytes and scattered ill - defined foci of larger actively dividing cells termed prolymphocytes.

44. 44Small Lymphocytic Lymphoma .

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46. 46SLL/CLL Morphology:The foci of mitotically active cells are called,“ Proliferatin Centers” , their presence are pathognomonic for CLL/SLLMitosis: rare

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48. The larger cells, the prolymphocytes, are the characteristic cells of the proliferation center. In some small lymphocytic lymphomas they are scattered instead of collected into centers.

49. CLL

50. 50SLL/CLLTransformation of SLL/CLL into “Prolymphocytic Leukemia” or “Diffuse Large B cell Lymphoma” (Richter's syndrome) is rare.The median Survival is less than 1 Year

51. 51SLL/CLL Immunophonotype Pan B markers CD20, CD19 CD5,CD23

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53. 53SLL/CLL Karyotypetrisomy 12, del 11q, del 13qPoor prognosis

54. Hairy Cell LeukemiaRare chronic lymphoproliferative disorder characterized by circulating B lymphocytes that display prominent cytoplasmic projectionsNeoplastic B cells infiltrate the marrow(diffusely) and spleen(red pulp) in a characteristic way

55. 2 to 3 percent of all adult leukemias Predominantly a disease of middle-aged males with a median age at presentation of 52 yearsM:F 4:1

56. Clinical FeaturesPancytopeniasplenomegalycirculating hairy cellsInfection from a wide variety of typical and opportunistic organisms

57. Laboratory FeaturesAnemia, thrombocytopenia, and leukopeniaAbsolute neutropenia and monocytopenia(80%)Hairy cells –Mononuclear cells with eccentric or central nucleiNuclear morphology is variable: round, ovoid, reniform, or convolutedReticular chromatin patternCytoplasm that is blue–gray, exhibiting thin cytoplasmic projections

58. MarrowMarrow involvement may be diffuse or focalHairy cells have monotonous round, oval, or spindle-spaced nuclei that are separated by abundant quantities of pale-staining cytoplasm in a fine fibrillar networkThe separation of individual hairy cells is characteristic and referred to as the "fried-egg" appearance

59. Marked marrow reticulin fibrosis, the marrow frequently is difficult or impossible to aspirate Hairy cells synthesize and assemble a fibronectin matrix that likely contributes to the marrow fibrosis characteristic of the disease

60. Spleen, Liver, and Lymph NodesThe spleen usually is enlarged, with a median weight of 1300 g On section, the spleen has a dark-red, smooth surfaceOn light microscopy, the hairy cells involve the splenic red pulp. Later, the white pulp atrophies and is replaced Red cell lakes, which are blood-filled spaces lined by hairy cells that have disrupted the normal sinus architecture, are characteristicThese blood-filled spaces are referred to as pseudosinuses

61. Hepatic infiltration is both sinusoidal and portalLymph node involvement is marked by both sinusoidal and interstitial involvement

62. CytochemistryStrongly positive for TRAP90 percent of cases Weak to moderate TRAP staining may occur in other diseases, including prolymphocytic leukemia and lymphoma

63. Electron MicroscopyCircumferential cytoplasmic projectionsRibosomal lamella complexes can be in 50 percent of patients

64. Immunophenotypic ProfileMature B cells, express the pan B cell antigens CD19, CD20, and CD22, but not CD21, an antigen lost in the later stages of B cell developmentMost distinctively, hairy cells express high levels of CD11c, CD22, CD25, and CD103

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66. Annexin A1 most specific marker Always compare with B cell antigen Since it is also expressed in myeloid cells and a proportion of T cells

67. HCL vs HCL- v Compare to HCL HCL-v haveLeucocytosisMonocytosisCell Prominent nucleoliBlastic or convoluted nuclei Variant immunophenotype(absent CD25,annexin A1 and TRAP)

68. Course and PrognosisWith treatment survival rate 10 year more than 90%Long term have increased risk of second malignancy

69. Splenic B cell marginal zone lymphomaB cell neoplasm composed of small lymphocytes which surround and replace the splenic white pulp germinal centersPeripheral blood ,bone marrow and splenic hilar lymph nodes are often involvedLymphoma cell in peripheral blood as villus lymphocytes

70. Clinical featuresRare neoplasm ( <2% )Patient present with splenomegaly ,autoimmune thrombocytopenia or anemia Patient may be positive for hepatitis C

71. Morphology Spleen – central zone of small round lymphocytes replace germinal centre and merge with peripheral zone of marginal zone cellRed pulp – small nodules of larger cells and sheet of small lymphocytes

72. Bone marrow –nodular involvement (compare to diffuse involvement by hairy cell leukemia )Peripheral blood –cells with short polar villi

73. Immunophenotype Surface Ig M positive and mostly Ig D positiveCD20 and CD 79a positiveCD5,CD10,CD23,CD43,annexin A1 negative

74. PrognosisIndolent Response to chemotherapy is poor compare to other lymphoid leukemia

75. Mantle cell lymphomaRare type of lymphoma(3-10%) Lymph node involvement is most common Spleen and bone marrow can be involvedPeripheral blood 20-60% cases

76. MorphologyMonomorphic lymphoid population with nodular, diffuse, mantle or follicular growth pattern Cells are medium size with irregular nuclear contours, resembling centrocytes Blastoid, pleomorphic variant can be seen

77. ImmnophenotypeIntense surface IgM/IgDCD5,FMC-7,CD43 positiveCD10 and BCL 6 negativeCD23 negative or weakly positiveCyclin D1 is positive

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79. Prognosis Median survival 3-5 yearsMost of patient can not be cured

80. (CD5 +, CD10 -) CLL/SL or MCL? Lack of proliferation centres Irregular nuclear contours Interspersed histiocytes PAS positive vessels Increased mitoses CD23 and Cyclin D1

81. Follicular lymphomaMost common lymphoma in USA and western EuropeCompose of follicular center cell(centrocytes/centroblasts) with partially follicular pattern

82. Clinical featureMedian age is 6 decadeMainly involved lymph nodes,spleen,bone marrow, peripheral blood,waldeyer ringWidespread soft tissue involvement can occur

83. MorphologyLymph node – predominately follicular pattern, with closely packed follicles that efface normal architecture Centocytes and blasts are randomly distributed Tingible macrophages are absent

84. Bone marrow- characteristically paratrabecular region may spread to interstial areaPeripheral blood - Scant cytoplasm some cells show clefting

85. ImmunophenotypeSIg+,B cell marker CD19,CD20,CD22,CD79a positiveFollicular marker BCL6 and CD 10 positiveBCL2 positive(variable-higher grade less positive)CD5 and CD 43 negative

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87. CD5-CD10+ Follicular lymphoma?Morphological features CD10 &Bcl6 expressed in normal and neoplastic follicle centres Presence of large numbers of CD10 &Bcl6 positive cells outside follicles suggests FL Bcl2 distinguishes reactive follicles from FL

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89. PrognosisExtent of diseaseInternational prognostic index for FL : Histological grade

90. B cell prolymphocytic leukemiaAffects – peripheral blood, bone marrow and spleenProlymphocytes must exceeds 55% of lymphoid cellsMedian age 55-59 yearM:F ratio 1:1

91. Most patients with B symptomsMassive splenomegaly Absent lymphadenopathy Rapidly raising lymphocyte count( >100x10 9 )

92. MorphologyPeripheral smear Majority cells are( usually 90% ) prolymphocytes Medium sizeRound nucleusModerately condensed chromatin Prominent central nucleolus Small amount of faintly basophilic cytoplasm

93. Bone marrow Interstitial orNodular involvement

94. D/DBlastic variant of MCLSplenic marginal zone lymphomaCLL with increase number of prolymphocytes

95. ImmunophenotypeSurface IgM+/- IgDB cell antigens –CD 19,CD20,CD22,CD79aCD5- 20-30%CD23- 10-20%

96. Prognosis Respond poorly to therapies for CLLMedian survival 30-50 months

97. T cell and Nk cell lymphomas

98. LymphomaMedian agePeripheral bloodCytopeniaBMspleenLymph nodeskinprognosisT cell prolymphocytic leukemia65Yes,prolymphocytesAnemia ,thrombocytopeniadiffuseDensered pulpDiffuse,paracorticalYes without epidermotrophismAggressive ,survival < 1 yearT cell large granular lymphocytic leukemia 65Yes,large granular lymphocytesSevere neutropenia+/-anemiaIntrasinusoidal,interstialRed pulp invovmentnonoindolantAdult T cell leukemia /lymphoma50 (20-80)Yes ,flower cellVariableyesyesGeneralized yesVariable Sezary syndrome70Yes,sezary cellNonoyesyesyesAggressiveCLPD of NK cells60Yes rareIntrasinusoidal,interstialnononoindolentAgg. NK cell leukemia42Yes,variable morphologycommonYes Yes uncommonuncommonfuminant

99. Mature T cell lymphomas

100. T cell prolymphocytic leukemiaAggressive lymphomaProliferation of small to medium sized prolymphocytes in peripheral blood, bone marrow, lymph node, liver, spleen and skin

101. Clinical featuresRare lymphoma (<2%)Median age 55 yearPatient present with hepatosplenomegaly and generalized lymphadenopathy Skin is involved in 20% of casesLymphocyte count is usually >100x109/l

102. MorphologyPeripheral blood Small to medium cellNon granular basophilic cytoplasm Round to oval or markedly irregular nucleiVisible nucleolus25% cases no nucleolus (small cell variant)Presence of cytoplasmic blebs or protrusions

103. Bone marrowDiffuse involvementCutaneousPerivascular or diffuse dermal infiltration without epidermotrophismSpleenDense red pulp infiltrationLymph nodeParacortical infiltration

104. ImmunophenotypePositive for CD2, CD3, CD7Negative for TdT and CD1aCD4+ , CD8- : 60% CD4 -, CD8 +: 25%CD4 -, CD8 +: 15%

105. Prognosis Aggressive Median survival less than 1 year

106. T cell large granular lymphocytic leukemiaHeterogonous disorderPersistent (more than 6 months) lymphocytosis (2-20x109/l)Large granular lymphocytes

107. Clinical feature 2-3% of lymphoma M:F =1:1Age range 45-75 yearInvolve PB, BM, liver, spleen.Lymphadenopathy is very rare

108. Splenomegaly main physical findingVarying degree of cytopeniaMainly severe neutropenia Autoimmune diseases common

109. Morphology Peripheral blood LGL withModerate to abundant cytoplasmFine or coarse azurophillic granules Bone marrow –mainly interstitial/sinusoidal involvement Spleen –red pulp cords and sinusoids involvement

110. Immunophenotype Positive for CD3,CD8 and T cell receptor αβMay be negative for CD5 and CD7

111. Prognosis Indolent course and non progressive Really neoplasm of uncertain significance or leukemia?

112. Chronic lymphoproliferative disorders of NK cells Heterogonous disorderPersistent (more than 6 months) lymphocytosis (2-20x109/l)NK cells proliferationWithout identifiable cause

113. Clinical featuresMedian age 60 yearMajority are asymptomatic Some with systemic symptoms and/or cytopenia

114. MorphologyNK cells are Intermediate sizeRound nucleusCondensed chromatin Moderate amount of slightly basophillic cytoplasmFine or coarse azurophillic granules Bone marrowIntrasinusoidal and inerstitial infiltration

115. ImmunophenotypeSurface CD 3 negativeCD 16 positiveCD56 weak positive Cytotoxic markers like TIA1,granzyme B and granzyme M positiveCD5 CD7 may be lostCD5 and CD8 may be aberrantly expressed

116. Prognosis Indolent clinical coursePatient may die because of cytopenia

117. Aggressive NK-cell leukemiaSystemic neoplastic proliferation of NK cellsAlmost associated with EB virus

118. Clinical featureRare form of leukemia Middle agePeripheral blood, bone marrow liver and spleen involvement Patient present with fever ,constitutional symptoms and leukemic blood pictureVarying degree of cytopenia

119. MorphologyRange of appearance from cells indistinguishable from large granular lymphocytes to cells with atypical nuclei featuring enlargement , irregular folding, open chromatin or distinct nucleoliAmple amount of basophillic cytoplasm containing fine or azurophillic granules

120. Bone marrow shows massive, focal or subtle infiltration by the neoplastic cells intermingled with histiocytes and hematophagocytosis

121. ImmunophenotypeSurface CD3 negativeCells positive are CD2,CD56 and cytotoxic molecules

122. Prognosis Fulminant courseComplicated by multiorgan failure , coagulopathy and hemophagocytic syndromeMedian survival less than 2 months

123. Adult T cell leukemia/lymphomaPeripheral T cell neoplasmHighly pleomorphic lymphocytes Caused by human T cell leukemia virus type 1

124. Clinical features Latent courseCumulative risk of ATLL is 2.5%InvolveLymph nodes Peripheral bloodOther Bone marrowSkin (most common extralymphatic site)Spleen,lung ,CNS,GI tract

125. Clinical variants-acute, lymphomatous , chronic, smolderingAcute (most common)-like leukemic phaseIncrease WBC count,skin rash, generalized lymphadenopathy,hypercalcemia, lytic bone lesionLymphomatous variantProminent lymphadenopathy without PB involvment

126. Chronic variant Exfoliative skin rash, no numerous atypical lymphocytes Smoldering variant WBC count normal with more than 5% atypical cell

127. MorphologyBroad spectrum of cytological features Peripheral blood Polylobated appearance –flower cellsDeeply basophillic cytoplsamLymph node –Hodgkin lymphoma like pictureDermal –like mycosis fungoides

128. Immunophenotype CD2,CD3,CD5 positiveCD7 negativeCD25 positive in all cases

129. Prognosis Clinical subtypesAgePerformance statusCalcium levelSerum LDH level

130. Sezary syndromeTriad of ErythrodermaGeneralized lymphadenopathyClonally related neoplastic T cells with cerebriform nuclei in skin ,lymph nodes and peripheral bloodIn addition(one or more criteria)Absolte sezary cell count at least 1000 cells per mm3CD4/CD8 ratio more than 10Loss of one or more T cell antigen

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132. Clinical featureRare < 5% of all cutaneous T cell lymphoma.Age more than 60 yearGeneralized diseaseAll visceral organ involved except bone marrow Patient present with erythroderma and generalized lymphadenopathy

133. MorphologyMorphological feature similar to mycosis fungoides Along with infiltration of lymph node and peripheral blood

134. Immunophenotype CD2 CD3 CD5 positiveLack CD7 Skin homing receptor CCR4 positive

135. PrognosisAggressive diseaseOverall survival at 5 year is 10-20 %

136. TREATMENTDepending on the nosological diagnosis and the stage of the disease, lymphoma treatment is based on the use of polychemotherapy and radiotherapy programs. As cytostatic agents, cyclophosphamide, rubomycin, vincristine, prednisolone (CHOP program) and some other drugs are most often used.In the absence of leukemia, there is a good opportunity for intensive chemotherapy followed by transplantation of autologous bone marrow harvested from the patient before intensive treatment. In addition to autotransplantation, under appropriate conditions, allogeneic bone marrow transplantation is used to treat lymphomas.

137. Thank you